Physician-Peer Relationships and Patient Experiences With Specialist Care
Authors: Maximilian J. Pany, J. Michael McWilliams
Journal: JAMA Internal Medicine (2023)

Importance Peer relationships may motivate physicians to aspire to high professional standards but have not been a major focus of quality improvement efforts. Objective To determine whether peer relationships between primary care physicians (PCPs) and specialists formed during training motivate improved specialist care for patients. Design, Setting, and Participants In this quasi-experimental study, difference-in-differences analysis was used to estimate differences in experiences with specialist care reported by patients of the same PCP for specialists who did vs did not co-train with the PCP, controlling for any differences in patient ratings of the same specialists in the absence of co-training ties. Specialist visits resulting from PCP referrals from 2016 to 2019 in a large health system were analyzed, including a subset of undirected referrals in which PCPs did not specify a specialist. Data were collected from January 2016 to December 2019 and analyzed from March 2020 to October 2022. Exposure The exposure was PCP-specialist overlap in training (medical school or postgraduate medical) at the same institution for at least 1 year (co-training). Main Outcomes and Measures Composite patient experience rating of specialist care constructed from Press Ganey’s Medical Practice Survey. Results Of 9920 specialist visits for 8655 patients (62.9% female; mean age, 57.4 years) with 502 specialists in 13 specialties, 3.1% (306) involved PCP-specialist dyads with a co-training tie. Co-training ties between PCPs and specialists were associated with a 9.0 percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4 percentage points; P &amp;amp;lt; .001), analogous to improvement from the median to the 91st percentile of specialist performance. This association was stronger for PCP-specialist dyads with full temporal overlap in training (same class or cohort) and consistently strong for 9 of 10 patient experience items, including clarity of communication and engagement in shared decision-making. In secondary analyses of objective markers of altered specialist practice in an expanded sample of visits not limited by the availability of patient experience data, co-training was associated with changes in medication prescribing, suggesting behavioral changes beyond interpersonal communication. Patient characteristics varied minimally by co-training status of PCP-specialist dyads. Results were similar in analyses restricted to undirected referrals (in which PCPs did not specify a specialist). Concordance between PCPs and specialists in physician age, sex, medical school graduation year, and training institution (without requiring temporal overlap) was not associated with better care experiences. Conclusions and Relevance In this quasi-experimental study, PCP-specialist co-training elicited changes in specialist care that substantially improved patient experiences, suggesting potential gains from strategies encouraging the formation of stronger physician-peer relationships.